Use of Simulation to Integrate Behavioral Health Into Primary Care Nurse Practitioner Programs.

BACKGROUND: Identifying and treating acute and chronic behavioral health conditions is integral to primary care practice, yet primary care nurse practitioner (NP) training models do not meet the demand for integrated behavioral health practices. Simulation offers an effective pedagogical tool for integrating behavioral health training in primary care. METHOD: With support from federal funding and external consultants, new didactic and complementary simulation curricula in integrated behavioral health care were introduced in the primary care and psychiatric mental health NP programs at a school of nursing. Two rounds of this curricular innovation were implemented and evaluated across specialties. RESULTS: Ninety-seven students participated in the training and reported enhanced behavioral-health assessment and hand-off skills, greater confidence in applying core content, and improved communication skills. CONCLUSION: Thoughtfully designed simulation offers an important tool for developing integrated behavioral health competencies that will help prepare future primary care clinicians meet the needs of patients and communities. [J Nurs Educ. 2024;63(2):128-133.].

Primary care nurse practitioners' perceptions and experiences communicating with adults about adverse childhood experiences.

BACKGROUND: Clinical communication focused on childhood adversity has not been well described in the extant literature. There is a wealth of knowledge about patient-centered communication, including patient-centered communication techniques involving the discussion of health risks in primary care. However, there remain gaps in our understanding of the role that communication plays in exploring adverse childhood experience (ACE) exposure among adults in the clinical context. PURPOSE: To better understand factors that influence how nurse practitioners (NPs) communicate with adults about ACEs in the context of primary care while simultaneously exploring NPs' perceptions and experiences of their ability to communicate with adults about ACE exposure. METHODOLOGY: Guided by the Patient-to-Provider Communication of Adverse Childhood Experiences in Primary Care (PPC-ACE) Model, an exploratory, qualitative, descriptive study was conducted among 15 US-based primary care NPs. Nurse practitioner's participated in semistructured interviews, which were recorded and transcribed. Transcripts were analyzed using inductive thematic analysis. Atlas.ti provided supplemental data visualization. Demographic data, practice characteristics, and baseline ACEs knowledge were collected by means of Qualtrics. RESULTS: Key themes described communication approaches and perceived barriers and facilitators to ACE-related conversations. Scope of practice, provider biases, diversity in practice models, and secondary trauma were factors NPs' perceived as positively or negatively influencing ACE-related communication in primary care. CONCLUSIONS: Outcomes from this study provided deeper insights into the various influencers of NP-perceived, ACE-related, patient-centered communication among adults in primary care. IMPLICATIONS: Findings will inform future research focused on ACE-related communication in primary care in the domains of NP education, practice, and health policy.

A mixed-methods pilot examination of Montana, North Dakota nurse practitioner telepresence behaviors through web-camera eye-tracking and qualitative descriptive interviews.

BACKGROUND: The use of telehealth for mental health-related encounters has increased exponentially since the COVID-19 pandemic. However, little is known how nurse practitioners (NPs) in rural areas establish connection and presence with patients through telehealth. PURPOSE: To leverage web-camera eye-tracking technology coupled with qualitative interviews to better understand rural NPs' perceptions, beliefs, experiences, and visual cues of connection and presence during mental health-related telehealth encounters. METHODS: This mixed-methods study employed web-camera eye-tracking technology to measure eye contact, facial/body movements with microexpressions, and auditory expressions during a simulated mental health-related telehealth visit. A qualitative descriptive methodology was used to conduct semistructured interviews with participants regarding utilization of telehealth in rural mental health care delivery. Sticky software, R, and STATA were used for the quantitative eye-tracking and demographic data analyses. Qualitative findings were analyzed using inductive thematic analysis. RESULTS: Ten NPs participated in the eye-tracking aspect of the study; among them, three completed semistructured interviews. Eye-tracking areas of interest were significant for the number of fixations (p = .005); number of visits (p < .001); time until notice (p < .001); and time viewed (p < .001). The category Workflow had the greatest number of thematic units (n = 21) derived from semistructured interviews. CONCLUSIONS: Although an accessible means of obtaining data, web-camera eye tracking poses challenges with data usability. This prompts further attention to research, optimizing the telehealth milieu to lessen patient and provider frustrations with technological or environmental issues. IMPLICATIONS: Nurse practitioners provide a key voice in the design and deployment of telehealth platforms congruent with the comprehensive assessment and presence of remote care delivery.

Scaling and Root Planing in a Patient with Atherosclerosis, Arrhythmia, and Anticoagulation.

Patients with cooccurring coronary artery disease and arrhythmias are frequently encountered by dental providers. Individuals with comorbid cardiovascular disease who require dual anticoagulant and antiplatelet therapy are a clinical challenge with regard to the need to balance the risks and benefits of intensive antithrombotic therapy. Modifications to dental care will need to be individualized considering the current disease state and medical management. Oral health promotion and good oral hygiene measures are recommended among this population.

Restorative Treatment in a Patient with Symptomatic Valvular and Structural Heart Disease.

Heart failure (HF) and valve replacements are common conditions encountered by dental professionals. Identification and differentiation between acute versus chronic HF symptoms will be key to providing safe and effective dental care. Vasoactive agents should be used cautiously in individuals with advanced HF. People with underlying cardiac conditions that put them at an increased risk of developing infectious endocarditis require antibiotic prophylaxis before all dental procedures. Establishing and maintaining optimal oral health is necessary to minimize the risks of bacterial seeding from the oral cavity to the heart.

Crown Preparation in a Patient with Hypertension and Type 2 Diabetes Mellitus.

Management of the diabetic dental patient should focus on the delivery of comprehensive dental care with an emphasis on maintaining periodontal health. Gingivitis, periodontitis, and associated bone loss independent of plaque accumulation are associated with poorly controlled diabetes. Periodontal status should be monitored carefully in patients with diabetes and underlying disease managed aggressively. Likewise, the dental team plays an important role in the identification of hypertension and managing dental-related side effects of anti-hypertensives.

Treatment of a Mandibular Abscess in a Patient with Coronary Artery Disease and Intermittent Angina.

An in-depth understanding of coronary artery disease will be critical to providing safe and effective dental care. Individuals with ischemic heart disease are at increased risk for anginal symptoms during dental care. Consultation with a cardiologist is advisable to ascertain cardiac stability for dental care if a patient has undergone recent coronary artery bypass graft surgery (less than 6 months ago). Judicious use of vasoactive agents during dental treatment is recommended. Antiplatelet and anticoagulant medications should be continued and local hemostatic measures used to control bleeding.

A Patient with Permanent Cardiac Pacemaker, History of Stroke Presents for an Extraction of Mandibular Molar Tooth.

Poor oral health and/or dental disease are highly prevalent among stroke survivors. Muscle weakness and loss of dexterity can decrease the patient's ability to provide effective oral hygiene post-stroke. Modifications to dental treatment should be based on the degree of neurologic sequelae, including scheduling needs. Special considerations must be taken with individuals who have permanent cardiac pacemakers.

Complete Denture Fabrication in a Patient with Chronic Obstructive Pulmonary Disease and Active Tobacco Use.

Patients with chronic obstructive pulmonary disease (COPD) have varying degrees of compromised airway function that can affect their ability to tolerate dental treatment. Thus, the delivery of dental care to individuals with COPD may need to be modified based on an understanding of the severity and control of the patient's disease, exacerbating factors, frequency of signs/symptoms, and disease management protocols. There is a strong association between aspiration of plaque organisms and pneumonia in individuals with COPD. Good oral hygiene and tobacco cessation education can help mitigate COPD exacerbations.

A Patient with a History of Extrinsic Asthma Presents for Endodontic Therapy for the Upper Molar.

With increasing rates of asthma in the general population, dental professionals need to be able to recognize the signs and symptoms of poorly controlled asthma and modify dental treatment accordingly. Prevention of an acute asthma exacerbation is key. Patients should be reminded to bring their rescue inhaler with them to every dental appointment. Patients who are using inhaled corticosteroids to manage their asthma are at greater risk of oral candidiasis, xerostomia, and caries. Regular dental visits and good oral hygiene are important among this population.

Restorative Treatment in a Patient with Chronic Obstructive Pulmonary Disease, Ischemic Heart Disease, and Arrhythmia.

Cardiovascular diseases are among the most common medical problems in the general population. Individuals with underlying cardiac conditions require special considerations with regard to appropriateness of dental treatment and precautions needed to deliver safe and effective care. Patients with unstable cardiac disease are at higher risk of developing complications during dental treatment. Similarly, comorbid conditions among patients with ischemic heart disease, such as chronic obstructive pulmonary disease, can further affect dental health and treatment, and they often require more individualized dental approaches.

An Initial Visit in a Patient with a History of Tuberculosis.

As public health stewards, dental providers must be mindful of actual of potential infectious disease risks. Tuberculosis (TB) is a leading cause of death in adults worldwide and is spread via aerosolized droplets. Individuals at the greatest risk of contracting TB are those with impaired immunity or those who have a higher risk of being exposed to an infection due to environmental factors. Dental providers must be aware of the clinical and public health implications of treating people with active versus latent TB infections.

Periodontal Maintenance in a Patient with a Lung Transplantation Post-COVID-19 Infection.

Early dental screening and treatment before and after solid organ transplantation are recommended infection prophylaxis measures. Dental treatment after transplantation should only be rendered after a discussion with the patient's health-care provider and/or transplant surgeon to determine the patient's stability for dental care. Potential sources of acute or chronic oral infections should be evaluated at every visit. Periodontal evaluation and through dental prophylaxis should be performed. Oral hygiene instruction including the importance of maintaining excellent oral health after transplant should be reviewed.

A Conceptual Model to Guide Patient-to-Provider Communication of Adverse Childhood Experiences in Primary Care: The PPC-ACE Model.

Communicating with adults about childhood adversity is not an innate clinical skill nor is it a routine assessment element. Nurse practitioners may be aware of the significance adverse childhood experience (ACE) exposure has on adult health and well-being; however, they may not be prepared to identify, interpret, and subsequently act on that information. This article presents the development of a conceptual model to guide patient-to-provider communication of adverse childhood experiences in primary care (the PPC-ACE model). This includes a description of the model and its associated foundational elements, underlying assumptions, implications for nursing practice, and opportunities to use this model to guide future ACEs-related research.

The current state of patient-to-provider communication of childhood adversity in primary care.

BACKGROUND: There is a wealth of literature focused on the task of adverse childhood experiences (ACEs) screening; however, little literature exists describing the broader process of ACE-related communication, specifically between nurse practitioners (NPs) and adult primary care patients. Consequently, there is no standardized process for communicating about ACEs in primary care and significant gaps remain related to how, when, and where these conversations occur. OBJECTIVES: To systematically examine peer-reviewed published literature from 2011 to 2021 to describe the current state of patient-to-provider communication about ACEs in primary care. DATA SOURCES: Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, a focused literature search for the dates January 1, 2011 through January 1, 2021 using the search engines CINAHL, PubMed, Ovid, and PsycINFO with inclusion criteria of "adverse childhood experiences," "communication," and "primary care" provided boundaries for this systematic review. CONCLUSIONS: Findings revealed that effective communication about childhood adversity is an integral and understated element when addressing ACE exposure among adult primary care patients. Further research focused on how primary care NPs apply the concepts of effective communication while providing clinical care to adults with histories of childhood adversity is warranted. IMPLICATIONS FOR PRACTICE: This systematic review will serve as a catalyst for informing future research, theory development, and curricular initiatives focused on enhancing communication between primary care NPs and adult patients with histories of childhood adversity. From a clinical perspective, this will illuminate opportunities to develop NP-centered approaches that emphasize identification, interpretation, documentation, and development of individual, ACE-specific interventions among adults with ACE exposure in primary care.

The elephant in the room: A concept analysis of communication and childhood adversity among adults.

BACKGROUND: Effective communication by those providing clinical care to adult patients is required to identify and address health disparities associated with childhood adversity. Many primary care NPs are unaware of these relationships, often lacking the communication skills and training needed to elicit this clinically relevant information. OBJECTIVES: A systematic review in the form of a concept analysis was undertaken to increase our understanding about patient-to-provider communication of childhood adversity in the context of the primary care setting. Two key concepts, communication and childhood adversity, were examined using the procedures outlined by Walker and Avant. DATA SOURCES: A focused literature search using the search engines CINAHL, PubMed, and PsycINFO with inclusion criteria of "adverse childhood experiences (ACE)," "childhood adversity," and "communication" provided boundaries for this analysis. No results were found using the defined conceptual terms. Therefore, concept synthesis was driven by the exploration of seminal and current literature from several disciplines. CONCLUSIONS: Findings revealed that effective communication about childhood adversity is an integral and understated element when addressing ACE-related health disparities among adults. Further synthesis is warranted to explore how primary care NPs apply the concepts of effective communication when providing clinical care to adult patients with histories of childhood adversity. IMPLICATIONS FOR PRACTICE: This concept analysis will serve as a catalyst for informing future research and theory development focused on enhancing ACE-specific communication between NPs and adult patients, which will lead to more personalized approaches to developing novel, ACE-specific interventions, a reduction in health disparities, and improved health outcomes.

Invisible pollution: the impact of pharmaceuticals in the water supply.

During the past decade, interest in the public and environmental health effects of trace levels of pharmaceuticals and personal care products in the water supply has evolved. Although most pharmaceuticals are tested for human safety and efficacy prior to marketing and distribution, the potential for adverse effects in nontarget populations exposed to minute environmental medication doses has not been established. Several recent studies have demonstrated adverse effects from longstanding, low-dose exposures in both aquatic and terrestrial wildlife, although human toxicity related to trace levels of pharmaceuticals in the water supply remains unknown. This article provides a brief overview of the routes through which pharmaceuticals are introduced into the environment; a description of the effects of longstanding, low-dose exposures in aquatic and terrestrial animals, including human health effects; an update on the current regulations and solutions regarding pharmaceutical disposal practices; and a discussion of implications for reducing pharmaceuticals in the environment for occupational health nurses and other allied health professionals.